Cleveland Clinic London Pioneers Use of AI in Medicines Administration

Before leaving the UK and as part of Conjure's Interfacing the Future event, ‘Blurring the Divide’, I have spoken with people who have made use of pioneering technology to augment the human experience. I was excited to speak with Francine de Stoppelaar, who is a trailblazer in this field. Francine is the Director of Pharmacy?at Cleveland Clinic London as well as an Associate Professor at the University of Leicester and has successfully implemented the first Closed Loop Medicines Administration (CLMA) system in the UK. She trained as a pharmacist in the Netherlands before coming to the UK about twenty years ago to work for the NHS. Francine then moved across to the independent sector, as a Chief Pharmacist at the Wellington Hospital in London, before becoming an independent consultant to support hospitals through their Care Quality Commission (CQC) inspections, operational models and governance processes. Francine joined Cleveland Clinic London around five years ago and they set her a huge challenge - to organise an entirely unique pharmacy medicines optimization model that copies the one used in the United States. Fortunately, Francine’s background as an experienced clinical pharmacologist informed her approach and helped her to engage with the Medicines and Healthcare products Regulatory Agency (MHRA) and the CQC.?

Francine takes up the story, “The first thing I did was to meet with the MHRA because we needed to do something that had never been done before in the UK - which was producing Unit Doses, and I wasn’t sure of the legalities. Unit Doses aren’t available in the UK even though you can buy them in the US and mainland Europe. They are individually barcoded tablets and capsules, which can be tracked throughout a hospital using digital technologies, from pharmacy to bedside administration. The MHRA came back to me after a couple of months with a decision and new legal framework stating we do not need a manufacturing licence providing we produce unit doses whilst maintaining the original packaging and expiry dates and only to use them at Cleveland Clinic London.”?

Francine explained how this system benefits the patient, “The main aim of using Unit Doses is to be able to barcode scan medication at a patient's bedside to identify whether the right medication is given to the right patient, at the right dose, at the right time, through the right route and the right documentation.”?

There are statistics highlighting the problems all hospitals face with medicines administration, globally as well as in the UK. A report by Professor Rachel Elliot (Elliott R, Camacho E, Campbell F, Jankovic D, Martyn St James M, Kaltenthaler E, Wong R, Sculpher M, Faria R, (2018). Prevalence and Economic Burden of Medication Errors in The NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication errors in the UK. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Universities of Sheffield and York predicted that in 2018 there were still 237 million medication errors a year throughout primary and secondary care in the UK. About 54% of those could have been bedside medication administration errors in hospitals.

It’s also predicted that around 1,700 deaths per year could possibly be prevented if these errors didn’t occur.

Hence, the drive to introduce final safety checks at the bedside during medicines administration. With this in mind, I wanted to know whether the CLMA system has the possibility to increase patient safety and Francine assured me, “Happily we are now in a position where we have had a significant reduction in medication errors at the bedside, after well over 180,000 bedside medication administrations, though we’re still optimising our services and workflows all the time. Eight months ago, we became the first in the UK to roll out this system throughout the entire hospital.”?

Cleveland Clinic London’s patient management system, Epic, operates all of the clinical and non-clinical services at Cleveland Clinic London including the comprehensive paperless digital system used in CLMA. Artificial intelligence is also used in the loop and is provided in the form of a particular robot that Francine needed to source.

The robot is the first of its kind to be operational in the UK.

It was built in Italy before being shipped to the Cleveland Clinic London in many different parts and it then took around three months to be put together before staff could be trained in how to operate it.?

At Cleveland Clinic London all medicines must be electronically prescribed and as an extra safety check, prescriptions must be verified by a pharmacist in real-time. So what role does the robot play? “The robot is fed strips of capsules and tablets. It uses artificial intelligence to set cutting templates for all the strips and then it cuts them using laser cutting techniques,” Francine tells me. “We then over-package them, individually calling out the medication, the dose, the lot number and expiry date, creating a unique barcode, which is used throughout the Unit Dose’s entire journey in the hospital. We then scan them into our automated carousels before re-scanning them into our automated secure medicines cabinets.”?

The nurses then take the Unit Doses out of the automated medicines cabinets on the wards and Francine explains the routine, “The nurses see for example, that at 1 o'clock, Mr Johnson needs Ramipril, 2.5 milligrams so they pull this up on the screen on the automated medicines cabinet and one drawer pops open, containing the medication in a pocket. The nurse takes the medicine out of that pocket and then takes it to the patient’s bedside, where the medicine’s barcode is scanned again along with the barcode on the patient’s wristband. At this point, Epic will check whether it is the right medication, given at the right time, for the right time, at the right dose and via the right route... When the medicines are administered, Epic will register it as administered and also automatically decrements stock. We then have automated carousels down in the pharmacy that starts turning and tells us when we need to top up that particular pocket in that particular machine, so doing this as part of the workflow makes our operations more efficient. To us, patient safety and putting patients first, are the absolute main components of this implementation process but, at the same time, it also reduces medicine waste and we're financially more efficient.?

So the loop is automated as far as possible, but there is the need for human intervention at certain stages, such as getting the medicines into the robot, into the carousels and in and out of the automated dispensing cabinets. Also, there are occasions when the robot needs maintenance or there are some medication strips that the robot can’t process and technicians in the pharmacy need to step in to manually cut the strips into individual tablets and label them with barcodes that come out of Epic. At the moment, Francine tells me, the system works on an 80% robot /20 % manual basis but she is confident that they are working towards maximising the use of the robot.?

Cleveland Clinic London now operates the CLMA system throughout the entire hospital but, knowing that it's been a long haul getting to this stage, I asked about the timeline. Francine reckons that it took at least two and a half to three years of preparation to find, procure and commission the right solutions. Her team needed to go through the bidding processes, visit sites and companies to look at robots and then they had to design and implement workflows. Epic needed to be built so that it took on board the necessary medicines, formulations and protocols comprising the pharmacy system of the hospital, and this in itself took at least a year and a half. Also, there were 85 automated dispensing cabinets, a unit dose robot and two automated carousels to be commissioned. The full process involved many hours of project management, for example, there were between 1500 and 2000 medications that needed procurement and wholesale contracts needed to be arranged with various companies.?

“So, to answer how long it took to implement this CLMA process - I came on board in January 2018, as a permanent Director of Pharmacy. We then opened our Outpatient building in September 2021 and the system went live as we opened the hospital at the end of March 2022,” Francine concludes. Throughout this period we dealt with Brexit, a global pandemic and a global supply chain crisis.?

Other areas of automation where Cleveland Clinic London has led the way in the UK, is the use of automated dispensing fridges and automated dispensing cabinets in theatres. The latter has caused changes in workflow for the anaesthetists and they have had to adapt to them.?

The Epic system is built on the fact that Cleveland Clinic London pharmacy is operating 24/7, which is normal in the US but unusual in the UK. Francine explains, “We need pharmacists and technicians working overnight to verify medications as soon as they are prescribed, as well as produce infusions and supply medications If the verification step doesn’t happen then our automated dispensing machines won’t open, so the cycle, or loop, is interrupted. Therefore it is no longer closed from an automation and digital perspective.” This 24/7 model presents a challenge as at least two technicians, an assistant, and one or two pharmacists must work overnight and it's not always easy to recruit good people to fill those shifts.?

Although challenges have been met along the way, it does sound as though the implementation of CLMA has been a huge success for Francine and her team at the Cleveland Clinic London and so I asked about future plans to roll out the idea.?Francine told me that she has a Continuous Improvement Manager, who looks at all the processes in the automation and digital area, to ensure the quality of service in the future.”?

To spread the word about the use of digital technology and AI in medicine administration, Francine is taking part in a panel speaking, “I spoke at the Patient Safety Congress a few months ago, I also spoke on a panel at an automation company congress in Athens. I think that because we've created something so unique, I'm being looked at as an expert and as someone to speak with in terms of ‘How do we do this?’ and, "Can you support us in helping us understand whether we can do this?”.

Cleveland Clinic London has also become something of a Centre of Excellence for others to learn from and attracts a number of visitors says Francine: “We’ve had visitors from the various hospitals and universities, particularly to see our robot but also to experience the entire CLMA system. “ Among the visitors are physicians and chief pharmacists from outside the UK as well. “They're citing us as an example and are really keen to implement what we're doing because they love our ideas, and see how this can improve safety,” Francine tells me.?

Given that CLMA has the possibility to significantly reduce bedside medication administration errors and improve efficiencies, I asked Francine what the biggest barrier is to prevent others from adopting this system. The answer, not surprisingly, is to do with budgets.?

“It’s very easy for me to say that we’ve developed this wonderful system and it’s amazing, but if you mention this in front of teams from other healthcare providers they will ask me how much it costs. And I can see their point. I was appointed to bring this model to the UK by the Cleveland Clinic in the US because it is something that the company strongly believes in and they supported me to find a way to implement it. So that's an entirely different situation to another provider saying, ‘this is what we should do to prevent deaths and be safe, however, how are we going to pay for this?’ “?

However, Francine has a logical response to this and says, “When I mention the actual investment for our robots and automation, it isn't as significant as you might think. But it does require a lot of effort and years of preparation and project management. There is often a very short-term mentality based on the belief that there is no budget available for such a medicines administration system. However, if you look at the amount of litigation, the costs, the heartache of readmissions to theatres, unexpected readmissions to hospitals, patients being ill, family members struggling, and so on... If you can prevent all of that it makes sense to make the investment in a system that will make patient care safer.”?It would be difficult to roll it out in the UK across all hospitals, but I can see that if a long-term vision was adopted, with the knowledge that investment is short-term but the long-term gain is significant, then this could all change.?

Beyond patient safety, another advantage of CLMA is that it facilitates the audit trail of medications moving through the hospital as Francine explains, “It definitely reduces medication waste, because we’re able to track Unit Doses throughout the hospital. Therefore, if medication is not needed onwards, we can put them back into our stock. We have financial efficiencies because the barcode audit trail means we can track stock accurately, and charge accurately and operational efficiencies mean we can save on staffing costs.”?

I finished our conversation by asking Francine what her plan is for the next 5-10 years, to which she immediately laughed and said, “I would say I need a bit of rest after this!”, then continued, “ Though it has given me lots of ideas around drawing more attention to what we have done and possible future collaborations. Of course, rolling this out on a larger scale would be a dream, but how to push new ideas forward? One way will involve being a consultant and advising other companies on how to do this with best practices." Leaving Francine with her thoughts I’m sure she won’t rest for long, she has plenty more trails to blaze!